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Chapter 10 Medical Staff Organization and Malpractice Diagnosis
▸ DIAGNOSIS Medical diagnosis is not always an easy task. Making an accurate diagnosis involves
the process of identifying a patient’s illness. Patient assessments, reassessments,
and test results (e.g., imaging and laboratory studies) are some of the tools of
medicine that assist providers in diagnosing the possible causes of a patient’s
symptoms and medical problems. An accurate diagnosis provides the practitioner
with alternative treatment options. The cases presented here describe a variety of
lawsuits that have occurred due to misdiagnoses.
Failure to Order Diagnostic Tests A plaintiff who claims that a physician failed to order proper diagnostic tests must
show the following:
It is standard practice to use a certain diagnostic test under the circumstances of the
case.
The physician failed to use the test and therefore failed to diagnose the patient’s
illness.
The patient suffered injury as a result.
Ophthalmologist Fails to Order Tests
In Gates v. Jensen, a lawsuit was brought against Dr. Hargiss, an ophthalmologist,
and others for failure to disclose to Mrs. Gates that her test results for glaucoma
were borderline and that her risk of glaucoma was increased considerably by her
high blood pressure and myopia. Hargiss failed to perform a field vision test and to
dilate and examine the eye. He wrote off the patient’s problem of difficulty in
focusing and gaps in vision as being related to difficulties with her contact lenses.
Gates visited the clinic 12 times during the following 2 years with complaints of
blurriness, gaps in her vision, and loss of visual acuity. Gates eventually was
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diagnosed with glaucoma. By the time Gates was properly treated, her vision had
deteriorated from almost 20/20 to 20/200. The court held that a duty of disclosure
to a patient arises whenever a physician becomes aware of an abnormality that may
indicate risk or danger. The facts that must be disclosed are those facts the
physician knows, or should know, of which a patient needs to be aware to make an
informed decision on the course of future medical care.
Once a physician concludes that a particular test is indicated, it should be
performed and evaluated as soon as practicable. Delay may constitute negligence.
The law imposes on a physician the same degree of responsibility in making a
diagnosis as it does in prescribing and administering treatment.
Misdiagnosis of Appendicitis
Failure to order diagnostic tests resulted in the misdiagnosis of appendicitis in
Steeves v. United States.
In this case, physicians failed to order the appropriate diagnostic tests for a child
who was referred to a Navy hospital with a diagnosis of possible appendicitis.
Judgment in this case was entered against the United States, on behalf of the U.S.
Navy, for medical expenses and for pain and suffering. The patient was given a test
that indicated a high white blood cell count. A consultation sheet was given to the
mother, indicating the possible diagnosis. The physician who examined the patient
at the Navy hospital performed no tests, failed to diagnose the patient’s condition,
and sent him home at 5:02 PM, some 32 minutes after his arrival on July 21. The
patient was returned to the emergency department on July 22, at about 2:30 AM,
and was once again sent home by an intern who diagnosed the patient’s condition
as gastroenteritis. No diagnostic tests were ordered. The patient was returned to the
HOW NOT TO BECOME A MEDICAL MYSTERY
No one wants to be a medical mystery. But it’s easy to become one.
While diagnosis may seem straightforward, the process can be surprisingly complex, strewn with cognitive land mines, logistical roadblocks, and red herrings. These complexities—and wrong turns—help create the medical mysteries.
—Tresa Baladas
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Navy hospital on July 23, at which time diagnostic tests were performed. The patient
was subsequently operated on and found to have a ruptured appendix.
Holding the Navy hospital liable for the negligence of the physicians who acted as its
agents, the court pointed out that a wrong diagnosis will not in and of itself support
a verdict of liability in a lawsuit. However, a physician must use ordinary care in
making a diagnosis. Only where a patient is examined adequately is there no liability
for an erroneous diagnosis. In this instance, the physicians’ failure to perform
further laboratory tests the first two times the child was brought to the emergency
department was found to be a breach of good medical practice.
Efficacy of Test Questioned A medical malpractice action was brought against Mambu in Sacks v. Mambu for
failure to make a timely diagnosis of Sacks’s colon cancer. It was alleged that Mambu
was negligent in that he failed to properly screen Sacks for fecal occult blood to
determine whether there was blood in the colon.
Because of complaints of fatigue by the patient, Mambu ordered blood tests that
revealed a normal hemoglobin, the results of which suggested that Sacks had not
been losing blood. However, by late July 1984, Sacks experienced symptoms of
jaundice. Mambu ordered an ultrasound test, and Sacks was subsequently
diagnosed with a tumor of the liver. He was admitted to the hospital and diagnosed
with having colon cancer. By the time the cancer was detected, it had invaded the
wall of the bowel and had metastasized to the liver. Sacks died in March 1985.
The trial court entered judgment on a jury verdict for Mambu, and the plaintiff
appealed. The Pennsylvania Superior Court upheld the decision of the trial court.
The jury determined that the physician’s failure to administer the test had not
increased the risk of harm by allowing the cancer to metastasize to the liver before
discovery and, therefore, was not a substantial factor in causing the patient’s death.
Although the presence of blood in the stool may be suggestive of polyps, cancer,
and a variety of other diseases, not all polyps and cancers bleed. Physicians are
therefore in disagreement as to the efficacy of the test.
In another case, at the age of five the plaintiff began to complain about chest pains
and trouble breathing. The symptoms reported and the initial testing suggested that
the plaintiff either had asthma or cystic fibrosis. Without further testing, the
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plaintiff’s physician reached a diagnosis of cystic fibrosis and ordered treatment
based on that diagnosis. Treatment included daily prescription medication and over
3,000 hours of painful percussion and vibration chest therapy. During percussion
and vibration therapy a machine was used to palpitate the chest of the plaintiff in
order to break up any secretions in the lungs and clear his airways for improved
breathing.
In addition to the treatment, the diagnosis took a psychological toll on the patient.
The patient was told that he would never be able to have children, his life
expectancy was approximately 30 years, and he would eventually have to undergo
lung transplant surgery. When the plaintiff entered his preteen years his parents
began to question the diagnosis and educated themselves on the disease.
After reaching out to the physician multiple times with no response, the parents
decided to get a second opinion from a consulting physician. The consulting
physician ordered a new test specifically to diagnose cystic fibrosis. The new test
came back negative. In the opinion of the consulting physician the plaintiff was
never appropriately tested and did not have cystic fibrosis. In this case the jury
found in favor of the plaintiff, and awarded him $2 million, which was the cap on
medical malpractice damages at the time in Virginia.
Failure to Promptly Review Test Results Can a physician’s failure to promptly review test results be the proximate cause of a
patient’s injuries? The answer is yes. In Smith v. U.S. Department of Veterans Affairs, the plaintiff, Smith, was first diagnosed as having schizophrenia in 1972.
He had been admitted to the Veterans Affairs (VA) hospital psychiatric ward 15 times
since 1972. His admissions grew longer and more frequent as time passed. On the
occasion of his March 17, 1990, admission, he had been drinking in a bar, got into a
fight, and was eventually taken to the VA hospital. Dr. Rizk was assigned as Smith’s
attending physician. Smith developed an acute problem with his respiration and
level of consciousness. It was determined that his psychiatric medications were
responsible for his condition. Some medications were discontinued, and others
were reduced. An improvement in his condition was noted.
By March 23, Smith began to complain of pain in his shoulders and neck. He
attributed the pain to more than 20 years of service as a letter carrier and to
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osteoarthritis. His medical record indicated that he had similar complaints in the
past. A rheumatology consultation was requested and carried out on March 29. The
rheumatology resident conducted an examination and noted that Smith reported
bilateral shoulder pain increasing with activity as an ongoing problem since 1979.
Various tests were ordered, including an erythrocyte sedimentation rate (ESR).
Smith was incontinent and complained of shoulder pain. By the afternoon, he was
out of restraints, walked to the shower, and bathed himself. On returning to his
room, he claimed that he could not get into bed. He was given a pillow and slept on
the floor. By the morning of April 4, Smith was lying on the floor in urine and
complaining of numbness. His failure to move was attributed to his psychosis. By
evening, it was noted that Smith could not lift himself and would not use his hands.
On April 5, a medical student noted that Smith was having difficulty breathing and
called for a pulmonary consultation. By evening, Smith was either unwilling or
unable to grasp a nurse’s hand and continued to complain that his legs would not
hold him up.
On the morning of April 6, Smith was complaining that his neck and back hurt and
that he had no feeling in his legs and feet. Later that day, a medical student noted
that the results of Smith’s ESR was 110 (more than twice the normal rate for a man
his age). His white blood cell count was 18.1, also well above the normal rate. A staff
member noted on the medical record that Smith had been unable to move his
extremities for approximately 5 days. A psychiatric resident noted that Smith had
been incontinent for 3 days and had a fever of 101.1°F.
On the morning of April 7, Smith was taken to University Hospital for magnetic
resonance imaging of his neck. Imaging revealed a mass subsequently identified as
a spinal epidural abscess. By the time it was excised, it had been pressing on his
spinal cord too long for any spinal function to remain below vertebrae 4 and 5.
The plaintiff brought suit alleging that the physicians’ failure to promptly review his
test results was the proximate cause of his paralysis. Following a bench trial, the U.S.
District Court agreed, holding that the negligent failure of physicians to promptly
review laboratory test results was the proximate cause of the plaintiff’s quadriplegia.
Of primary importance was the plaintiff’s ESR of 110; the test results were available
on the patient care unit by April 2 but were not seen, or at least not noted in the
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record, until April 6. An elevated ESR generally accounts for one of three problems:
infection, cancer, or a connective tissue disorder. Most experts agreed that, at the
very least, a repeat ESR should have been ordered. The VA’s care of the plaintiff fell
below the reasonable standard of care in that no one read the laboratory results
until April 6. The fact that the tests were ordered mandates the immediate review of
the results. Although it cannot be known with certainty what would have occurred
had the ESR been read and acted upon on April 2, it is certain that the plaintiff had a
chance to fully recover from his infection. By April 6, that chance was gone.
Due to the absence of notes from Rizk in the plaintiff’s chart, it is impossible to know
whether Rizk was aware of the plaintiff’s symptoms. However, it appears that the
absence of notes by Rizk indicated that Rizk’s care of the plaintiff was negligent, and
the failure to review the lab results constituted negligence under the relevant
standard of care. That led to the failure to make an early diagnosis of the plaintiff’s
epidural abscess, which was the proximate cause of the patient’s eventual paralysis.
It was foreseeable that ignoring a high ESR could lead to serious injury.
A mechanism should be in place to expeditiously notify the patient’s physician of
abnormal test results. Computer systems help ensure physicians are notified of
critical lab data so that appropriate care decisions can be implemented.
Timely Diagnosis A physician can be liable for reducing a patient’s chances for survival. The timely
diagnosis of a patient’s condition is as important as the need to accurately diagnose
a patient’s injury or disease. Failure to do so can constitute malpractice if a patient
suffers injury as a result of such failure.
Failure to Read X-Ray Report
On February 5, 1988, Mr. Griffett was taken to the emergency department with a
complaint of abdominal pain. Two emergency department physicians evaluated
him and ordered X-rays, including a chest X-ray. Dr. Bridges, a radiologist, reviewed
the chest X-ray and noted in his written report that there was an abnormal density
present in the upper lobe of Griffett’s right lung.
Griffett was referred to Dr. Ryan, a gastroenterologist, for follow-up care. Ryan
admitted Griffett to the hospital for a 24-hour period and then discharged him
without having reviewed the radiology report of the February 5 chest X-ray. On
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March 1, 1988, Griffett continued to experience intermittent pain. A nurse in Ryan’s
office suggested that Griffett go to the hospital emergency department if his pain
became persistent.
In November 1989, Dr. Baker examined Griffett, who was complaining of pain in his
right shoulder. Baker diagnosed Griffett’s condition as being cancer of the upper
lobe of his right lung. The abnormal density on the February 5, 1988, chest X-ray was
a cancerous tumor that had doubled in size from the time it had been first
observed. The tumor was surgically removed in February 1990; however, Griffett
died in September 1990.